KLA Healthcare Consultants
Medicare Well Patient Physical
|Type of |___IPPE – Welcome to Medicare – Select |___Initial AWV w/PPPS – G0438 |___Subsequent AWV w/PPPS – G0439 |
|Wellness |G0402, G0403, G0404 or G0405 |(1 time only after 1st 12 months of Medicare |(Annually at least 12 months after Initial |
|Exam: |(1 time during first 12 months on Medicare)|B eligibility AND 1 year after IPPE.) |AWV w/PPPS) |
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|Medicare Part B |Date of Last |Date of Last |Sex: |Date: |
|Eligibility Date: |Exam: |IPPE or AWV: | | |
|Vital signs: |
___Reviewed patient-completed individual and family history with patient. Significant findings and/or changes were noted on patient’s history form and include:
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|See continuation sheet?_____Yes_____No |
___Reviewed patient’s chronic and acute problem list and risk factors with patient. Significant findings and/or changes were noted on patient’s problem list and include:
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|Educational materials were given to and discussed with patient: _____Yes ____No |
| If yes, describe: |
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|Screenings, testings and referrals recommended and noted on patient’s personalized schedule of health services. _____Yes ____No |
|See continuation sheet?_____Yes_____No |
___Reviewed patient-completed list of providers and suppliers regularly involved in patient’s care was with patient. Significant findings and/or changes were noted on patient’s provider and supplier list and include:
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|See continuation sheet?_____Yes_____No |
___Reviewed patient-completed list of allergies with patient. Significant findings and/or changes were noted on patient’s allergy list and include:
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|See continuation sheet?_____Yes_____No |
___Reviewed medication list with patient and updated. Significant findings and/or changes were noted on patient’s medication list and include:
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|See continuation sheet?_____Yes_____No |
___Reviewed hospitalization list with patient and updated. Significant findings and/or changes were noted on patient’s hospitalization list and include:
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|See continuation sheet?_____Yes_____No |
Assessment of any Cognitive Impairment:
|General appearance: |
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|Mood/affect: |
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|Input from others: |
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|Patient cognitive impairment tested with CANS-MCI® _____Yes ____No (If Yes remember 96103 & 96120) |
| If yes, results: |
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|Notes and plan: |
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|See continuation sheet?_____Yes_____No |
Depression Screening:
|Over the past two weeks, the patient expresses little interest or pleasure in doing things: _____Yes _____No |
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|Over the past two weeks the patient felt down, depressed or hopeless: _____Yes _____No |
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|Notes and plan: |
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|See continuation sheet?_____Yes_____No |
Functional Ability:
|Does the patient exhibit a steady gait? _____Yes _____No |
|How long did it take the patient to get up and walk from a sitting position? |
|Is the patient self reliant? (ie can he/she do own laundry, prepare meals, do household chores) _____Yes _____No |
|Does the patient handle his/her own medications? _____Yes _____No |
|Does the patient handle his/her own money? _____Yes _____No |
|Is the patient’s home safe (ie good lighting, handrails on stairs and bath, etc.)? _____Yes _____No |
|Did you notice or did patient express any hearing difficulties? _____Yes _____No |
|Did you notice of did patient express any vision difficulties? _____Yes _____No |
|Were distance and reading eye charts used? _____Yes _____No |
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|Notes and plan: |
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|See continuation sheet?_____Yes_____No |
Advance Care Planning: (At discretion of patient)
|Patient was offered the opportunity to discuss advance care planning: _____Yes _____No |
|Does patient have an Advance Directive: _____Yes _____No |
|If no, did you provide information on Caring Connections? _____Yes _____No |
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|Notes and plan: |
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|See continuation sheet?_____Yes_____No |
EKG Results: (Not mandatory)
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|See continuation sheet?_____Yes_____No |
Other Relevant Findings:
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|Notes and plan: |
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|See continuation sheet?_____Yes_____No |
Provider’s Signature: Date:
Schedule of Personalized Health Plan
(Provide Copy to Patient)
|Service |Medicare Coverage Requirements |Date of Most |Provider |Date |
| | |Recent Service |Recommendation |Scheduled |
|Vaccines | | | | |
|• Pneumococcal (once after 65) | | | | |
|• Influenza (annually) | | | | |
|• Hepatitis B (if medium/high | | | | |
|risk) | | | | |
| | | | | |
| |Medium/high risk factors: Endstage renal disease | | | |
| |Hemophiliacs who received Factor VIII or | | | |
| |IX concentrates | | | |
| |Clients of institutions for the mentally retarded | | | |
| |Persons who live in the same house as a | | | |
| |HepB virus carrier | | | |
| |Homosexual men | | | |
| |Illicit injectable drug abusers | | | |
|Mammogram (biennial age 50-74) |Annually (age 40 or over) | | | |
|Pap and pelvic exams (up to age |Ever y 24 months except high risk | | | |
|70 and after 70 if unknown | | | | |
|history or abnormal study last | | | | |
|10 years) | | | | |
|Prostate cancer screening |Annually (age 50 or over), DRE not paid separately when | | | |
|(annually to age 75) |covered E/M service is provided on same date | | | |
|Digital rectal exam (DRE) | | | | |
|Prostate specific antigen (PSA)| | | | |
|Colorectal cancer screening (to | | | | |
|age 75) | | | | |
|• Fecal occult blood test | | | | |
|(annual) | | | | |
|• Flexible sigmoidoscopy (5y) | | | | |
|• Screening colonoscopy (10y) | | | | |
|• Barium enema | | | | |
|Diabetes self-management training|Requires referral by treating physician for patient with | | | |
|(no USPSTF recommendation) |diabetes or renal disease. | | | |
| |10 hours of initial DSMT sessions of no less than 30 | | | |
| |minutes each in a continuous | | | |
| |12-month period. 2 hours of follow-up | | | |
| |DSMT in subsequent years. | | | |
|Bone mass measurements |Requires diagnosis related to osteoporosis- sis or | | | |
|(age 65 & older, biennial) |estrogen deficiency. Biennial benefit unless patient has | | | |
| |history of long-term glucocorticoid use or baseline is | | | |
| |needed because initial test was by other method. | | | |
|Glaucoma screening (no USPSTF |Diabetes mellitus, family history | | | |
|recommendation) |African American, age 50 or over | | | |
| |Hispanic American, age 65 or over | | | |
|Medical nutrition therapy for |Requires referral by treating physician for patient with | | | |
|diabetes or renal disease (no |diabetes or renal disease. Can be provided in same year as| | | |
|recommended schedule) |diabetes self- management training (DSMT), and CMS | | | |
| |recommends medical nutrition therapy take place after | | | |
| |DSMT. Up to 3 hours for | | | |
| |initial year and 2 hours in subsequent years. | | | |
|Cardiovascular screening blood | | | | | |
|tests (every 5 years) | | | | | |
|• Total cholesterol | | | | | |
|• High-density lipoproteins | | | | | |
|• Triglycerides | | | | | |
|Diabetes screening tests |Patient must be diagnosed with one of the following: | | | |
|(at least every 3 years, |• Hyper tension | | | |
|Medicare covers annually or at |• Dyslipidemia | | | |
|6-month intervals for |• Obesity (BMI >30 kg/m2) | | | |
|pre-diabetic patients) |• Previous elevated impaired FBS or GTT | | | |
|• Fasting blood sugar (FBS) or|… or any two of the following: | | | |
|glucose tolerance test (GTT) |• Over weight (BMI >25 but ................
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